Management of Neurological Disorders (eBook)

Bryan Ashworth, Michael Saunders (Autoren)

eBook Download: PDF | EPUB

2013 | 2. Auflage
340 Seiten
Elsevier Science (Verlag)
978-1-4831-8262-9 (ISBN)

Infos

Management of Neurological Disorders: Second Edition presents a comprehensive guide on intensive care, rehabilitation, and the psychiatric aspects of neurology. It discusses the developments made in surgical treatment techniques. It addresses the management of coma patients. Some of the topics covered in the book are the psychological factors in intensive care; assessment of respiratory function; chronic respiratory disease, cardiac disease, and chest deformity; cardiac arrest and its neurological complications; removal of kidneys for transplantation; and organization of rehabilitation services. The general approach to neurological physiotherapy is fully covered. An in-depth account of the psychiatric aspects of neurology is provided. Depression associated with neurological disorders is completely presented. A chapter is devoted to the psychological aspects of epilepsy. Another section focuses on the pathological physiology of Parkinsonism. The management of visual failure, metabolic muscle disorders, acute bacterial meningitis, and viral encephalitis are briefly covered. The book can provide useful information to doctors, psychologists, therapists, students, and researchers.

Inhalt

Front Cover 1
Management of Neurological Disorders 4
Copyright Page 5
Table of Contents 10
Preface 6
Acknowledgements 8
Chapter 1. Intensive care 12
Respiratory failure 20
Cardiac arrest and its neurological complications 28
Brain-stem death 28
Chapter 2. Rehabilitation 32
Organization of rehabilitation services 33
Physiotherapy 34
Physical methods 34
General approach to neurological physiotherapy 36
Occupational therapy 38
The provision of aids 39
Speech therapy 40
Speech therapy in children 41
Dysphasia 42
Dysarthria 43
Neurological nursing 44
Severe disability and terminal care 45
Chapter 3. Psychiatric aspects of neurology 47
Measurement in psychiatry 47
Depression 48
Depression associated with neurological disorders 52
Mania 52
Schizophrenia and organic psychosis 53
Personality disorders and neurological disease 55
Iatrogenic psychiatric problems 59
Drug abuse 59
Chapter 4. The neurogenic bladder 64
Anatomy and physiology 64
Urodynamic investigations 66
Clinical assessment 67
Examples of disturbed bladder function 67
Management 69
Urinary infection 73
Chapter 5. Chronic pain 75
Anatomy 75
The relief of pain 77
Drug treatment of pain 78
Operative and chemical interruption of pain pathways 82
Miscellaneous procedures for pain relief 87
Specific pain problems 88
Chapter 6. Headache and facial pain 91
Acute headache and facial pain 91
Recurrent headache 94
Chronic headache 98
Chronic facial pain 99
Chapter 7. Epilepsy 100
Investigation 101
Differential diagnosis 102
Anticonvulsant drugs 103
Treatment 111
Epilepsy in childhood 113
All other types of epilepsy 116
Status epilepticus 117
Surgical treatment 119
Other therapies 119
Psychological aspects of epilepsy 122
Social aspects of epilepsy 123
Narcolepsy 127
Chapter 8. Parkinsonism and involuntary movement 128
Parkinsonism 128
Therapeutic measures 130
Involuntary movements 137
Wilson's disease 141
Chapter 9. Special senses 143
Olfaction and taste 143
Management of visual failure 144
Vertigo and deafness 147
Acoustic neuroma 151
Menière's disease 151
Vestibular neuronitis 152
Positional vertigo 153
Other causes of vertigo and deafness 153
Chapter 10. Dementia and degenerative disorders 154
The scope of the problem 154
Assessment of dementia 155
Management of dementia 157
Management of specific disorders 159
Degenerative disorders 160
Metabolic dementia 161
Dementia associated with primary and metastatic tumours 167
Infection 168
Chapter 11. Multiple sclerosis 169
Diagnosis 169
Classification 170
Management 171
Other demyelinating diseases 186
Chapter 12. Cerebral vascular disease 187
Cerebral haemorrhage 187
Occlusive vascular disease due to embolism or thrombosis 192
Management of the progressive stroke 197
Management of the established stroke 197
Chapter 13. Head injuries 200
Early assessment 200
Post-traumatic amnesia 202
Early management 202
Specific early complications 206
Late sequelae 209
Chapter 14. Cerebral tumours and raised intracranial pressure 213
Tumours involving the cerebral hemisphere 216
Posterior fossa tumours 217
Intraventricular tumours 220
Pineal and parapineal tumours 220
Shunts 222
Tumours involving the visual pathway 222
Diabetes insipidus (DI) 224
Leukaemia and reticulosis 225
Radiotherapy 226
The inoperable tumour 226
Chapter 15. Developmental disorders 228
Abnormalities of the cranium 229
Abnormalities near the foramen magnum 230
Abnormalities of the spinal cord 232
Cerebral palsy 235
Chapter 16. Spinal cord disorders 239
Physical signs 239
Differential diagnosis 240
Myelography 240
Acute spinai cord trauma 242
Rehabilitation 244
Myelitis 246
Vascular disease 246
Radiation myelopathy 247
Syringomyelia 247
Cervical and dorsal disc protrusion 248
Cervical spondylosis 249
Rheumatoid disease 251
Intraspinal tumours and cysts 251
Extradural compression 251
Intradural compression 253
Intramedullary neoplasms 254
Intraspinal cysts 255
Vascular tumours and malformations 255
Chapter 17. Disorders of the cranial nerves and peripheral nervous system 257
Cranial nerves 257
Peripheral nervous system 262
Spinal nerve roots 265
Peripheral nerves 271
Mononeuropathy 277
Traumatic neuropathy 281
Chapter 18. Motor neurone disease, myasthenia gravis and muscle disease 282
Motor neurone disease 282
Treatment and management 283
Myasthenia gravis 285
Neonatal myasthenia 291
Congenital myasthenia 291
Penicillamine myasthenia 291
Myasthenie syndrome 291
Muscular dystrophy and spinal muscular atrophy 292
Dystrophia myotonica and other myotonic syndromes 295
Dystrophia myotonica 295
Myotonia congenita (Thomsen's disease) 297
Paramyotonia 297
Other forms of muscular dystrophy and spinal muscular atrophy 297
Polymyositis 299
Polymyalgia rheumatica 300
Metabolic muscle disorders 301
Myopathy in hyperparathyroidism and osteomalacia 303
Chapter 19. Infections and infestations 304
Bacterial infections 304
Brain abscess 314
Other systemic bacterial infections that involve the nervous system 317
Viral infections of the nervous system 320
Neurological disorders associated with specific fevers 326
Cruetzfeldt-Jakob disease (CJD) (spongiform encephalopathy 327
Mycoses 327
Recommended reading 331
Index 334

Textauszug

1

Intensive care

Publisher Summary

This chapter provides an overview of intensive care. The number of neurological patients who need intensive care is small and insufficient to justify a unit for their exclusive use. Often they will be accommodated alongside patients with respiratory or cardiac disease. Under ideal conditions, the same facilities can be provided in a ward or room, but economy, organization, and the training of staff favor the grouping of patients. Careful selection of patients is essential. Intensive care is best confined to the management of patients judged likely to benefit significantly from the special supportive measures that are applied over a period of days or weeks. The harmful effects of raised intracranial pressure have long been recognized but continuous monitoring is a recent development. When a conscious patient is admitted for intensive care, he or she is faced with a strange environment and is often encumbered with intravenous lines and monitoring equipment while rendered mute by a tracheostomy. It is important that communication is maintained and some explanation given. Intensive care directed to the management of respiratory failure is important in some patients with disease of the nervous system. It is important that assisted respiration is considered for any patient who becomes breathless or has difficulty in coughing. Physicians in intensive care units prefer to observe doubtful cases rather than receive them at the stage of severe hypoxia.

The number of neurological patients who need intensive care is small, and insufficient to justify a unit for their exclusive use. Often they will be accommodated alongside patients with respiratory or cardiac disease. Under ideal conditions the same facilities can be provided in a ward or room but economy, organization, and the training of staff favour the grouping of patients.

Careful selection of patients is essential. Intensive care is best confined to the management of patients judged likely to benefit significantly from the special supportive measures that are applied over a period of days or weeks.

Staff

The work makes special demands on nursing and medical personnel. The nurse has greater responsibility than in an ordinary ward, and will often have to act quickly and initiate a prearranged programme of treatment. The staff must be fully trained and continuously available. The pace of events and the inevitable failures in treatment have an effect on morale. It is important that an atmosphere of calm and cheerfulness is created. The medical management also presents problems, and it must be clear to everyone concerned which consultant is responsible for the management of each patient. The skills of the anaesthetist are often required. The unit can conveniently be administered by a specialist in intensive care, an anaesthetist, or a chest physician. Regular consultation with other experts is essential.

Environment

The environment of the intensive care unit is highly significant, because most patients will have difficulty in concentrating on any activity other than their own treatment for longer than a few minutes. The room should provide adequate space, be well lit, and, if possible, have views that preserve contact with normal activities. In should be quiet and situated away from noisy corridors. Buzzers and flashing lights should be reduced to a minimum.

Observation and monitoring

Charting of the pulse rate, blood pressure, respiratory rate, core and skin temperature and fluid balance is usually a routine. The frequency of observations will vary with the case, and computer systems are useful for on-line recording.

Skin temperature is conveniently recorded using a thermocouple, and core temperature with a probe in the external auditory meatus or lower oesophagus. Rectal temperature measurements carry some risk of spread of infection. A continuous display of the cardiograph on an oscilloscope is useful. Central venous pressure can be monitored with a catheter in the right atrium. Chest radiographs must be easily obtained, usually with portable equipment. The blood pressure can be recorded continuously if an intra-arterial catheter is used.

These are basic requirements, but computers provide more elaborate records and automatic alarm signals. Closed-circuit television is no substitute for the presence of staff adjacent to the bed.

While these facilities can be expected in a unit, many aspects of intensive care impinge on daily management of patients who do not require all the facilities of the special unit. Some of these will now be considered in a general way to avoid repetitive discussion later in the book. No attempt is made to cover all aspects of the subject, and only points of special significance for the neurological patient will be discussed.

Monitoring of intracranial pressure

The harmful effects of raised intracranial pressure have long been recognized but continuous monitoring is a recent development. Lumbar puncture is potentially dangerous in these patients. The pressure may be measured by using a catheter inserted through a burr hole into the frontal horn of the lateral ventricle. The manometer system is attached to a transducer with a chart for continuous recording. Observations of this type show that very marked and sometimes rapid changes in pressure may occur in patients with intracranial tumour or haemorrhage (Figure 1.1 and Figure 1.2).

Figure 1.1 Monitoring intracranial pressure. A catheter is inserted into the lateral ventricle through a burr hole in the skull and connected to a manometer and transducer for pressure recording

Figure 1.2 Three sequences of intracranial pressure (ICP) recorded at intervals of 30 minutes. There is a rise in pressure and a corresponding increase in pulse pressure. (Reproduced by courtesy of Professor J. D. Miller and Messrs John Wright.)

The normal intracranial pressure with the patient lying flat is usually 0–10 mmHg or 0–13.6 cm H2O (7.5 mmHg = 1 kPa) and may increase tenfold during coughing or straining. The wave pattern is altered by arterial pulsation and respiration.

A rise in pressure to 40 mmHg may be regarded as moderate but it may reach much higher levels. Plateau waves rising abruptly to 50 mmHg and persisting for 30–60 minutes strongly suggest an intracranial mass lesion. A rise in pressure may be due to obstruction of cerebrospinal fluid (CSF) flow but brain oedema, stiffness of brain tissue, tentorial herniation, CO2 retention, hypoxia, restless sleep, pyrexia and general anaesthesia are important contributory factors. High CSF pressure interferes with blood flow and if it equals the arterial pressure brain perfusion ceases.

Treatment directed towards control of the pressure is likely to be needed if the level reaches 30 mmHg and action may be required at lower levels when other clinical signs show progression.

Pressure monitoring is most often required in severe head injury, cerebral haemorrhage, hydrocephalus and brain tumour.

Rising intracranial pressure not caused by airway obstruction, jugular compression, hypoxia, or postural change may be due to an expanding lesion which requires urgent surgical relief. As a temporary measure intravenous mannitol infusion of 200 ml of 20% solution may be used. This may be combined with intermittent positive pressure respiration and closed drainage of the ventricular fluid.

Recognition of change

The general observation and monitoring of the patient are designed to ensure early recognition of any deterioration.

In assessing conscious level, it is best to record the type of response, rather than rely on numerical or other grading which may vary in significance according to different observers. It is useful to record the patient’s conscious level in such terms as: alert, responding readily to command, responding to command but tending to lapse into a drowsy state when not stimulated (stupor), responsive to pinch or pinprick, response to supraorbital pressure, or unresponsive.

The Glasgow Coma Scale has been used mainly in the management of head injuries and was designed to monitor progress and provide a numerical index of prognosis. It is based on the ability of the patient to obey commands, speak, and open the eyes when these functions are not disturbed by local causes such as superficial haematoma or tracheostomy. The aggregate score (Figure 1.3) is in the range 3–15.

Figure 1.3 Glasgow Coma Scale for a patient with subarachnoid haemorrhage with response to intravenous mannitol given when clinical deterioration took place

The motor response to command must be distinguished from a grasp reflex or spinal reflex response. The best response is recorded. A pencil applied to the nail or skin is a suitable stimulus to induce pain. A localizing response to pain is based on retraction of a limb when stimulated at more than one site. An extensor response to pain is abnormal and found in decerebrate states.

The verbal responses are useful where the speech mechanism is intact and expression in words allows classification into ‘orientated’, ‘confused’, and...

Produkt-Details

• Erscheint lt. Verlag: 22.10.2013
• Sprache: englisch
• Themenwelt: Sachbuch/Ratgeber ► Gesundheit / Leben / Psychologie ► Krankheiten / Heilverfahren
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete
• Themenwelt: Studium ► 1. Studienabschnitt (Vorklinik) ► Anatomie / Neuroanatomie
• Themenwelt: Studium ► 2. Studienabschnitt (Klinik) ► Pathologie
• Themenwelt: Naturwissenschaften ► Biologie ► Biochemie
• Themenwelt: Naturwissenschaften ► Physik / Astronomie ► Angewandte Physik
• Themenwelt: Technik
• ISBN-10: 1-4831-8262-2 / 1483182622
• ISBN-13: 978-1-4831-8262-9 / 9781483182629